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Editor's blog Tuesday 7 June 2011: Emersonian Transcendentalism masks no real change in PM Cameron's NHS speech

“A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines.”
Ralph Waldo Emerson, ‘Self-Reliance’; founder of Transcendentalism

“Before I go on with this short history, let me make a general observation – the test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.”
F Scott Fitzgerald, ‘The Crack-Up’

PM David Cameron’s NHS reform speech started with an extempore bit praising the work of host venue UCLH in the London stroke reconfiguration. (Sir Robert Naylor will probably be glad when all this is over and he can have use of his lecture theatre again.)

The PM's choice of stroke reconfiguration was curious. It doesn’t address why Mr Cameron’s Health Secretary Andrew Lansley blocked the original service reconfiguration proposals from Healthcare For London, and then allowed them to happen unchanged after a wholly token consultation.

The stroke reconfiguration is improving care and saving lives and quality of lives because sometimes, planning is needed to reshape services. It has to be clinically led and enjoy buy-in, which the plan Lansley stopped and restarted did.

Planning, however, is against both the spirit and letter of the reforms Mr Cameron and Mr Lansley still back.


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The not-new
It was a curious speech, because almost everything in it has already been leaked or said. Longer timelines for the change has variously appeared in HSJ, as has the NHS Commissioning Board’s ‘no cash till ready’ stranglehold on consortia.

The PM announced ”we’re keeping the 18-week limit”, presumably unaware it had never gone away from its ineffectual place in the unenforceable NHS Constitution. The DH are going to continue not to centrally performance-manage it, as SOS Lansley insisited since he came into office. But I’m sure people will be reassured that it’s there. Won’t they?

There was one innovation: “clinical senates”. (But who will be the Emperor, and how many Legions has she?) No indication was offered of where they will sit, how they will be funded, to whom they will be accountable or if their advice will be binding or optional.

Oh, and will the clinical senates have a purchaser-provider split?

There are many contradictions here. I mean, aren’t clinical senates essentially new bureaucracy?

The most obvious contradiction, though, is that NHS managers and management are still being bashed (“empty bureaucracy”); yet ” waiting times really matter … we’re going to measure outcomes too”.

Um, doing stuff about waiting times and outcomes is a bureaucracy thing.

I am trying hard to ration my swearing, and so ‘piffle’ is the word I will use to characterise the PM’s response to the imaginary question “ask why didn’t we get everything right at the beginning”.

The PM’s answer was ”I know other governments would announce reforms, and just plough on regardless of the concerns people had, for fear of appearing indecisive or worrying about admitting something could be improved. And I know that the media with their deadlines want everything fixed in 24 hours. But this is too important to get wrong. So I think it is right that we took some time”.

Ah. Right. So the reason you didn’t get it right first time is because making the law about the NHS is important? And there’s a 24-hour news media, is there?

Now I’m reassured.

The politician’s syllogism
Life imitates art: life in public policy imitates Yes, Minister. I have been repeating the politician’s syllogism (1. Something must be done. 2. This is something. 3. Therefore this must be done) so often that even I am slightly bored by it.

Nonetheless, Cameron used that justification of his reforms today.

The competition solution
On competition, the PM said, ”I’ve heard doctors tell me they want more choice on behalf of their patients, but they want to be sure that competition is introduced in a properly managed and orderly way.

“And I’ve heard our hospital doctors say they are incredibly proud of what they do and quite prepared to be judged one hospital against another, one team against another, but fear the situation where a new operator can come in without any of the NHS overheads, costs and pensions and cherrypick their simplest cases”.

As if there were any doubt, Mr Cameron handlily added, ”I do believe competition is a good thing”.

Competition – no end
Mr Cameron then added, ” But not as an end in itself. It is a means to give doctors more choice to get the best possible care for their patients, and for patients to have that choice too. It is a means of bringing in fresh thinking, new ideas, different ways of doing things that deliver better and better value for money.

“Put simply: competition is one way we can make things work better for patients. This isn’t ideological theory … new providers, more choice and competition raises standards and delivers values for money”.

The word ‘choice’ crops up a lot: as Health Policy Insight pointed out, the three ‘C’s on which the White Paper bet the farm were choice, competition and commissioning.

It is used 15 times in the speech, which is a fair amount. Competition crops up 11 times. This wordle of the text is also interesting: NHS; patients; people; want; care.

The language around Monitor is interesting: ”as our legislation currently stands, Monitor, the health regulator, has a duty to promote competition. This could be misinterpreted and we don’t want any doubt in anyone’s mind.

“Monitor’s main duty is to protect and promote the interests of people who use health care services, and it will use competition as a means to that end. Not simply to promote it or prevent it, but to secure the services patients need. It will be tasked with creating a genuine level playing field, so the best providers flourish and patients get a real choice … I mean a real choice for patients. This is absolutely central to my vision for the NHS. This is a National Health Service, and I take the ‘service’ part seriously”.

More to the point, ” Monitor will now have a new duty to support the integration of services – whether that’s between primary and secondary care, mental and physical care, or health and social care”.

But that’s planning. And you don’t like planning.

Until we see some detail, I suspect that Monitor’s role may be, as I have previously written, capable of fairly swift amendment to restore the economic and competition regulation aspects.

Isn’t ideological theory?
The PM earlier stated that his view “isn’t ideological theory”, yet also said, ”one-size-fits all monolithic state provision can actually entrench disadvantage and deepen the disparities in service between regions, classes and racial groups in our society”.

Not ideological at all, that.

Enough to square the Lib Dems?
Oh, it might be enough. Perhaps the question now will be whether the Conservative Party’s right-wing MPs get restive.